Healthcare Provider Details

I. General information

NPI: 1760996102
Provider Name (Legal Business Name): MISTY ANDERSON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6138 MAIN ST
TURIN NY
13473
US

IV. Provider business mailing address

701 LENOX AVE
ONEIDA NY
13421-1500
US

V. Phone/Fax

Practice location:
  • Phone: 315-348-8406
  • Fax:
Mailing address:
  • Phone: 315-363-9281
  • Fax: 315-363-9286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number010644
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: